SEATTLE – More than one quarter of people with multiple sclerosis (MS) may be underemployed or unemployed, according to data presented at the annual meeting of the Consortium of Multiple Sclerosis Centers. The disease appears to prevent people from achieving their full potential at work and at home, largely because of its associated fatigue, said the researchers. “The economic impact of identifying an effective treatment for this symptom of MS cannot be overstated,” said Terrie Livingston, PharmD, head of patient outcomes and solutions at EMD Serono in Wayland, Massachusetts, and colleagues.

The research results from an initiative by the North American Registry for Care and Research in MS (NARCRMS). Since December 2016, NARCRMS has prospectively collected clinical and imaging data, information about patients’ health care economics, and data about the effects of MS on daily life. To examine the economic impact of MS and to help implement health economics outcomes research (HEOR) in decision-making processes, NARCRMS established the HEOR Advisory Group in 2017. The registry created a Health-Related Productivity Questionnaire and Health Resource Utilization Questionnaire, both of which were incorporated into the existing case report forms. Patients complete these questionnaires at enrollment and at annual and exacerbation visits.

As of January 2, 2019, NARCRMS had enrolled 378 people with MS into the registry, and 368 had completed the HEOR case report forms. Among the respondents, 270 (73%) are employed either full or part time. During the week before reporting, 39 respondents (11%) reported that MS kept them from work, 93 (25%) reported that MS affected their work, 105 (29%) reported that MS stopped them from finishing household chores, and 140 (38%) reported that MS affected their household chores. Fatigue was the symptom most commonly reported to affect work and household chores. In the 3 months before reporting, 13 patients (4%) had inpatient hospital stays, 24 patients (7%) visited the ED, 71 patients (19%) visited a general practitioner, and 296 (80%) patients visited a neurologist.

The study had no sponsor. Several of the study authors reported receiving compensation from companies such as Biogen, Celgene, Genentech, Novartis, Sanofi Genzyme, and Teva.

egreb@mdedge.com

SEATTLE – More than one quarter of people with multiple sclerosis (MS) may be underemployed or unemployed, according to data presented at the annual meeting of the Consortium of Multiple Sclerosis Centers. The disease appears to prevent people from achieving their full potential at work and at home, largely because of its associated fatigue, said the researchers. “The economic impact of identifying an effective treatment for this symptom of MS cannot be overstated,” said Terrie Livingston, PharmD, head of patient outcomes and solutions at EMD Serono in Wayland, Massachusetts, and colleagues.

The research results from an initiative by the North American Registry for Care and Research in MS (NARCRMS). Since December 2016, NARCRMS has prospectively collected clinical and imaging data, information about patients’ health care economics, and data about the effects of MS on daily life. To examine the economic impact of MS and to help implement health economics outcomes research (HEOR) in decision-making processes, NARCRMS established the HEOR Advisory Group in 2017. The registry created a Health-Related Productivity Questionnaire and Health Resource Utilization Questionnaire, both of which were incorporated into the existing case report forms. Patients complete these questionnaires at enrollment and at annual and exacerbation visits.

As of January 2, 2019, NARCRMS had enrolled 378 people with MS into the registry, and 368 had completed the HEOR case report forms. Among the respondents, 270 (73%) are employed either full or part time. During the week before reporting, 39 respondents (11%) reported that MS kept them from work, 93 (25%) reported that MS affected their work, 105 (29%) reported that MS stopped them from finishing household chores, and 140 (38%) reported that MS affected their household chores. Fatigue was the symptom most commonly reported to affect work and household chores. In the 3 months before reporting, 13 patients (4%) had inpatient hospital stays, 24 patients (7%) visited the ED, 71 patients (19%) visited a general practitioner, and 296 (80%) patients visited a neurologist.

The study had no sponsor. Several of the study authors reported receiving compensation from companies such as Biogen, Celgene, Genentech, Novartis, Sanofi Genzyme, and Teva.

egreb@mdedge.com

SEATTLE – More than one quarter of people with multiple sclerosis (MS) may be underemployed or unemployed, according to data presented at the annual meeting of the Consortium of Multiple Sclerosis Centers. The disease appears to prevent people from achieving their full potential at work and at home, largely because of its associated fatigue, said the researchers. “The economic impact of identifying an effective treatment for this symptom of MS cannot be overstated,” said Terrie Livingston, PharmD, head of patient outcomes and solutions at EMD Serono in Wayland, Massachusetts, and colleagues.

The research results from an initiative by the North American Registry for Care and Research in MS (NARCRMS). Since December 2016, NARCRMS has prospectively collected clinical and imaging data, information about patients’ health care economics, and data about the effects of MS on daily life. To examine the economic impact of MS and to help implement health economics outcomes research (HEOR) in decision-making processes, NARCRMS established the HEOR Advisory Group in 2017. The registry created a Health-Related Productivity Questionnaire and Health Resource Utilization Questionnaire, both of which were incorporated into the existing case report forms. Patients complete these questionnaires at enrollment and at annual and exacerbation visits.

As of January 2, 2019, NARCRMS had enrolled 378 people with MS into the registry, and 368 had completed the HEOR case report forms. Among the respondents, 270 (73%) are employed either full or part time. During the week before reporting, 39 respondents (11%) reported that MS kept them from work, 93 (25%) reported that MS affected their work, 105 (29%) reported that MS stopped them from finishing household chores, and 140 (38%) reported that MS affected their household chores. Fatigue was the symptom most commonly reported to affect work and household chores. In the 3 months before reporting, 13 patients (4%) had inpatient hospital stays, 24 patients (7%) visited the ED, 71 patients (19%) visited a general practitioner, and 296 (80%) patients visited a neurologist.

The study had no sponsor. Several of the study authors reported receiving compensation from companies such as Biogen, Celgene, Genentech, Novartis, Sanofi Genzyme, and Teva.

egreb@mdedge.com

Seattle – Among patients with multiple sclerosis (MS) who receive treatment with alemtuzumab, those with an Expanded Disability Status Scale (EDSS) score between 4.0 and 4.5 are most likely to achieve confirmed disability improvement, according to a pooled analysis presented at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Patients who achieved this outcome had improvement in several functional systems, regardless of their baseline EDSS scores. “These results suggest a broad and prolonged effect of alemtuzumab on disability improvement and a potential for changing the MS disease course,” said Samuel F. Hunter, MD, a neurologist and psychiatrist at the Advanced Neurosciences Institute in Franklin, Tenn., and colleagues.

The researchers’ findings come from their analysis of pooled data from the CARE-MS I and CARE-MS II trials. Those studies indicated that alemtuzumab improved clinical and MRI outcomes over 2 years in relapsing-remitting MS, compared with interferon beta-1a. In a 4-year extension, alemtuzumab’s efficacy was maintained, and 81% of participants continued in the study until year 6. In addition, 34% of alemtuzumab-treated patients in CARE-MS I and 43% of alemtuzumab-treated patients in CARE-MS II achieved 6-month confirmed disability improvement. The relationship between baseline disability levels and the achievement of disability improvement is not well understood, however.

Dr. Hunter and colleagues conducted a pooled analysis of CARE-MS I and CARE-MS II data to evaluate how baseline disability affects improvements in each functional system in patients treated with alemtuzumab over 6 years. In those studies, patients received two 12-mg/day courses of alemtuzumab: a 5-day course at baseline and a 3-day course 12 months later. Additional treatment with alemtuzumab or other disease-modifying therapies was provided as needed during the extension study.

The investigators defined confirmed disability improvement as a decrease of 1 or more points in EDSS score confirmed over 6 months among patients with a baseline EDSS score of 2 or higher. Improvement (i.e., a decrease of 1 or more points) or stability (i.e., no change) in each of the functional system scores was assessed in patients with confirmed disability improvement, stratified by baseline EDSS scores. Patients were grouped according to whether their baseline EDSS scores were 2.0-2.5, 3.0-3.5, 4.0-4.5, 5.0-5.5, or 6.0-6.5.

A total of 208 of 565 patients (37%) achieved 6-month confirmed disability improvement through year 6. This outcome was achieved by the highest percentages of patients with baseline EDSS scores of 4.0-4.5 (57%) and 3.0-3.5 (44%), followed by those with baseline EDSS scores of 5.0-5.5 (28%) and 2.0-2.5 (27%). No patients with baseline EDSS scores of 6.0-6.5 achieved confirmed disability improvement.

At 6 months after onset of confirmed disability improvement, patients within each baseline EDSS group showed stability or improvement in each individual functional system. The proportion of stable or improved patients was 94% or greater in the 2.0-2.5 group, 92% or greater in the 3.0-3.5 group, 88% or greater in the 4.0-4.5 group, and 75% or greater in the 5.0-5.5 group. Between 67% and 76% of patients achieved improvements in two or more functional systems. Improvements were most frequent in the pyramidal (13% to 50%), sensory (42% to 50%), and cerebellar (13% to 55%) functional systems.

Sanofi, Bayer HealthCare Pharmaceuticals supported the study. Dr. Hunter received grants and financial support from AbbVie, Actelion, Acorda, Adamas, Alkermes, Avanir, Bayer HealthCare, Biogen, Novartis, Osmotica, Questcor, Roche, Sanofi, Synthon, and Teva.

egreb@mdedge.com

SOURCE: Hunter SF et al. CMSC 2019. Abstract DXT08.

Seattle – Among patients with multiple sclerosis (MS) who receive treatment with alemtuzumab, those with an Expanded Disability Status Scale (EDSS) score between 4.0 and 4.5 are most likely to achieve confirmed disability improvement, according to a pooled analysis presented at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Patients who achieved this outcome had improvement in several functional systems, regardless of their baseline EDSS scores. “These results suggest a broad and prolonged effect of alemtuzumab on disability improvement and a potential for changing the MS disease course,” said Samuel F. Hunter, MD, a neurologist and psychiatrist at the Advanced Neurosciences Institute in Franklin, Tenn., and colleagues.

The researchers’ findings come from their analysis of pooled data from the CARE-MS I and CARE-MS II trials. Those studies indicated that alemtuzumab improved clinical and MRI outcomes over 2 years in relapsing-remitting MS, compared with interferon beta-1a. In a 4-year extension, alemtuzumab’s efficacy was maintained, and 81% of participants continued in the study until year 6. In addition, 34% of alemtuzumab-treated patients in CARE-MS I and 43% of alemtuzumab-treated patients in CARE-MS II achieved 6-month confirmed disability improvement. The relationship between baseline disability levels and the achievement of disability improvement is not well understood, however.

Dr. Hunter and colleagues conducted a pooled analysis of CARE-MS I and CARE-MS II data to evaluate how baseline disability affects improvements in each functional system in patients treated with alemtuzumab over 6 years. In those studies, patients received two 12-mg/day courses of alemtuzumab: a 5-day course at baseline and a 3-day course 12 months later. Additional treatment with alemtuzumab or other disease-modifying therapies was provided as needed during the extension study.

The investigators defined confirmed disability improvement as a decrease of 1 or more points in EDSS score confirmed over 6 months among patients with a baseline EDSS score of 2 or higher. Improvement (i.e., a decrease of 1 or more points) or stability (i.e., no change) in each of the functional system scores was assessed in patients with confirmed disability improvement, stratified by baseline EDSS scores. Patients were grouped according to whether their baseline EDSS scores were 2.0-2.5, 3.0-3.5, 4.0-4.5, 5.0-5.5, or 6.0-6.5.

A total of 208 of 565 patients (37%) achieved 6-month confirmed disability improvement through year 6. This outcome was achieved by the highest percentages of patients with baseline EDSS scores of 4.0-4.5 (57%) and 3.0-3.5 (44%), followed by those with baseline EDSS scores of 5.0-5.5 (28%) and 2.0-2.5 (27%). No patients with baseline EDSS scores of 6.0-6.5 achieved confirmed disability improvement.

At 6 months after onset of confirmed disability improvement, patients within each baseline EDSS group showed stability or improvement in each individual functional system. The proportion of stable or improved patients was 94% or greater in the 2.0-2.5 group, 92% or greater in the 3.0-3.5 group, 88% or greater in the 4.0-4.5 group, and 75% or greater in the 5.0-5.5 group. Between 67% and 76% of patients achieved improvements in two or more functional systems. Improvements were most frequent in the pyramidal (13% to 50%), sensory (42% to 50%), and cerebellar (13% to 55%) functional systems.

Sanofi, Bayer HealthCare Pharmaceuticals supported the study. Dr. Hunter received grants and financial support from AbbVie, Actelion, Acorda, Adamas, Alkermes, Avanir, Bayer HealthCare, Biogen, Novartis, Osmotica, Questcor, Roche, Sanofi, Synthon, and Teva.

egreb@mdedge.com

SOURCE: Hunter SF et al. CMSC 2019. Abstract DXT08.

Seattle – Among patients with multiple sclerosis (MS) who receive treatment with alemtuzumab, those with an Expanded Disability Status Scale (EDSS) score between 4.0 and 4.5 are most likely to achieve confirmed disability improvement, according to a pooled analysis presented at the annual meeting of the Consortium of Multiple Sclerosis Centers.

Patients who achieved this outcome had improvement in several functional systems, regardless of their baseline EDSS scores. “These results suggest a broad and prolonged effect of alemtuzumab on disability improvement and a potential for changing the MS disease course,” said Samuel F. Hunter, MD, a neurologist and psychiatrist at the Advanced Neurosciences Institute in Franklin, Tenn., and colleagues.

The researchers’ findings come from their analysis of pooled data from the CARE-MS I and CARE-MS II trials. Those studies indicated that alemtuzumab improved clinical and MRI outcomes over 2 years in relapsing-remitting MS, compared with interferon beta-1a. In a 4-year extension, alemtuzumab’s efficacy was maintained, and 81% of participants continued in the study until year 6. In addition, 34% of alemtuzumab-treated patients in CARE-MS I and 43% of alemtuzumab-treated patients in CARE-MS II achieved 6-month confirmed disability improvement. The relationship between baseline disability levels and the achievement of disability improvement is not well understood, however.

Dr. Hunter and colleagues conducted a pooled analysis of CARE-MS I and CARE-MS II data to evaluate how baseline disability affects improvements in each functional system in patients treated with alemtuzumab over 6 years. In those studies, patients received two 12-mg/day courses of alemtuzumab: a 5-day course at baseline and a 3-day course 12 months later. Additional treatment with alemtuzumab or other disease-modifying therapies was provided as needed during the extension study.

The investigators defined confirmed disability improvement as a decrease of 1 or more points in EDSS score confirmed over 6 months among patients with a baseline EDSS score of 2 or higher. Improvement (i.e., a decrease of 1 or more points) or stability (i.e., no change) in each of the functional system scores was assessed in patients with confirmed disability improvement, stratified by baseline EDSS scores. Patients were grouped according to whether their baseline EDSS scores were 2.0-2.5, 3.0-3.5, 4.0-4.5, 5.0-5.5, or 6.0-6.5.

A total of 208 of 565 patients (37%) achieved 6-month confirmed disability improvement through year 6. This outcome was achieved by the highest percentages of patients with baseline EDSS scores of 4.0-4.5 (57%) and 3.0-3.5 (44%), followed by those with baseline EDSS scores of 5.0-5.5 (28%) and 2.0-2.5 (27%). No patients with baseline EDSS scores of 6.0-6.5 achieved confirmed disability improvement.

At 6 months after onset of confirmed disability improvement, patients within each baseline EDSS group showed stability or improvement in each individual functional system. The proportion of stable or improved patients was 94% or greater in the 2.0-2.5 group, 92% or greater in the 3.0-3.5 group, 88% or greater in the 4.0-4.5 group, and 75% or greater in the 5.0-5.5 group. Between 67% and 76% of patients achieved improvements in two or more functional systems. Improvements were most frequent in the pyramidal (13% to 50%), sensory (42% to 50%), and cerebellar (13% to 55%) functional systems.

Sanofi, Bayer HealthCare Pharmaceuticals supported the study. Dr. Hunter received grants and financial support from AbbVie, Actelion, Acorda, Adamas, Alkermes, Avanir, Bayer HealthCare, Biogen, Novartis, Osmotica, Questcor, Roche, Sanofi, Synthon, and Teva.

egreb@mdedge.com

SOURCE: Hunter SF et al. CMSC 2019. Abstract DXT08.

The cost of oral cancer drugs increased by almost 6% over inflation from 2010 to 2018, leading to increases in out-of-pocket costs for Medicare patients despite reductions in the Part D coverage gap, according to an analysis of formulary and pricing data.

Point-of-sale prices for the 49 oral cancer drugs available before 2018 rose by 40.4% from 2010 to 2018 – an annual increase of 5.8% above the rate of inflation, Stacie B. Dusetzina, PhD, of Vanderbilt University, Nashville, Tenn., and associates reported in JAMA. Another five drugs with data that first became available in 2018 were not included in the cost-increase calculations.

The largest overall increase, 306% (16.2% above inflation per year), belonged to gefitinib (Iressa). Its point-of-sale price rose from $1,960 a month in 2010 to $7,960 in 2018. The award for largest reduction – only two others had a decrease – goes to the only generic available, imatinib. Its monthly cost dropped 44% (–28.1% below inflation per year) from $8,570 in 2016 to $4,822 in 2018, the investigators said (JAMA 2019 May 28;321[20]:2025-7).

Annual out-of-pocket spending for the 13 drugs available for the entire study period increased from $8,794 in 2010 to an expected $10,470 in 2019. Medicare patients’ out-of-pocket costs for those 13 cancer drugs in 2019 are expected to range from $7,220 for lapatinib to $15,472 for lenalidomide, they reported.

“Savings expected through closing the Part D coverage gap or through other policy changes, such as point-of-sale rebates, will be unlikely to offer financial protections to patients needing anticancer drugs. Moreover, because beneficiaries pay a percentage of the drug’s price and have no out-of-pocket spending limits on Part D, even large price decreases may not provide sufficient financial relief to patients requiring long-term anticancer drug use,” Dr. Dusetzina and associates wrote.

The study was supported by the Commonwealth Fund and the Leukemia and Lymphoma Society. The investigators reported receiving grant funding from the study funders.

rfranki@mdedge.com

The cost of oral cancer drugs increased by almost 6% over inflation from 2010 to 2018, leading to increases in out-of-pocket costs for Medicare patients despite reductions in the Part D coverage gap, according to an analysis of formulary and pricing data.

Point-of-sale prices for the 49 oral cancer drugs available before 2018 rose by 40.4% from 2010 to 2018 – an annual increase of 5.8% above the rate of inflation, Stacie B. Dusetzina, PhD, of Vanderbilt University, Nashville, Tenn., and associates reported in JAMA. Another five drugs with data that first became available in 2018 were not included in the cost-increase calculations.

The largest overall increase, 306% (16.2% above inflation per year), belonged to gefitinib (Iressa). Its point-of-sale price rose from $1,960 a month in 2010 to $7,960 in 2018. The award for largest reduction – only two others had a decrease – goes to the only generic available, imatinib. Its monthly cost dropped 44% (–28.1% below inflation per year) from $8,570 in 2016 to $4,822 in 2018, the investigators said (JAMA 2019 May 28;321[20]:2025-7).

Annual out-of-pocket spending for the 13 drugs available for the entire study period increased from $8,794 in 2010 to an expected $10,470 in 2019. Medicare patients’ out-of-pocket costs for those 13 cancer drugs in 2019 are expected to range from $7,220 for lapatinib to $15,472 for lenalidomide, they reported.

“Savings expected through closing the Part D coverage gap or through other policy changes, such as point-of-sale rebates, will be unlikely to offer financial protections to patients needing anticancer drugs. Moreover, because beneficiaries pay a percentage of the drug’s price and have no out-of-pocket spending limits on Part D, even large price decreases may not provide sufficient financial relief to patients requiring long-term anticancer drug use,” Dr. Dusetzina and associates wrote.

The study was supported by the Commonwealth Fund and the Leukemia and Lymphoma Society. The investigators reported receiving grant funding from the study funders.

rfranki@mdedge.com

The cost of oral cancer drugs increased by almost 6% over inflation from 2010 to 2018, leading to increases in out-of-pocket costs for Medicare patients despite reductions in the Part D coverage gap, according to an analysis of formulary and pricing data.

Point-of-sale prices for the 49 oral cancer drugs available before 2018 rose by 40.4% from 2010 to 2018 – an annual increase of 5.8% above the rate of inflation, Stacie B. Dusetzina, PhD, of Vanderbilt University, Nashville, Tenn., and associates reported in JAMA. Another five drugs with data that first became available in 2018 were not included in the cost-increase calculations.

The largest overall increase, 306% (16.2% above inflation per year), belonged to gefitinib (Iressa). Its point-of-sale price rose from $1,960 a month in 2010 to $7,960 in 2018. The award for largest reduction – only two others had a decrease – goes to the only generic available, imatinib. Its monthly cost dropped 44% (–28.1% below inflation per year) from $8,570 in 2016 to $4,822 in 2018, the investigators said (JAMA 2019 May 28;321[20]:2025-7).

Annual out-of-pocket spending for the 13 drugs available for the entire study period increased from $8,794 in 2010 to an expected $10,470 in 2019. Medicare patients’ out-of-pocket costs for those 13 cancer drugs in 2019 are expected to range from $7,220 for lapatinib to $15,472 for lenalidomide, they reported.

“Savings expected through closing the Part D coverage gap or through other policy changes, such as point-of-sale rebates, will be unlikely to offer financial protections to patients needing anticancer drugs. Moreover, because beneficiaries pay a percentage of the drug’s price and have no out-of-pocket spending limits on Part D, even large price decreases may not provide sufficient financial relief to patients requiring long-term anticancer drug use,” Dr. Dusetzina and associates wrote.

The study was supported by the Commonwealth Fund and the Leukemia and Lymphoma Society. The investigators reported receiving grant funding from the study funders.

rfranki@mdedge.com

Individuals who experienced adverse childhood experiences but also played team sports as teens were less likely to have mental health problems in adulthood than those with childhood challenges who did not play sports, based on data from nearly 5,000 individuals.

Mike Watson Images/Thinkstock

Physical and mental health problems are more prominent throughout life among those exposed to adverse childhood experiences (ACEs), and physical activity in general and team sports in particular have been shown to improve mental health, wrote Molly C. Easterlin, MD, of the University of California, Los Angeles, and colleagues.

In a study published in JAMA Pediatrics, the researchers used data from the National Longitudinal Study of Adolescent to Adult Health to compare the development of depression, anxiety, or depressive symptoms among those with childhood ACEs who did and did not participate in team sports in adolescence.

Overall, team sports participation was significantly associated with reduced odds of depression (adjusted odds ratio, 0.76), anxiety (aOR, 0.70), and depressive symptoms (aOR, 0.85) in young adulthood for individuals with ACEs, compared with those with ACEs who did not play team sports.

Of 9,668 adolescents in the study, 4,888 individuals reported one or more ACEs and 2,084 reported two or more ACEs. The researchers compared data from the 1994-1995 school year when participants were in grades 7-12 and in 2008 to assess their mental health as young adults (aged 24-32 years).

No significant differences in associations appeared between sports participation and mental health between males and females.

The results were limited by several factors including the study design that did not allow for causality and the potential social desirability bias that might lead to underreporting ACEs, Dr. Easterlin and associates noted.

Nonetheless, “given that participation in team sports was associated with improved adult mental health among those with ACEs, pediatricians might consider recommending team sports participation for patients with ACEs and parents might consider enrolling their children with ACEs in team sports,” they wrote.

Dr. Easterlin is supported by the Cedars-Sinai Medical Center via the UCLA National Clinician Scholars Program. The authors reported no conflicts of interest.

SOURCE: Easterlin MC et al. JAMA Pediatr. 2019 May 28. doi: 10.1001/jamapediatrics.2019.1212.

Individuals who experienced adverse childhood experiences but also played team sports as teens were less likely to have mental health problems in adulthood than those with childhood challenges who did not play sports, based on data from nearly 5,000 individuals.

Mike Watson Images/Thinkstock

Physical and mental health problems are more prominent throughout life among those exposed to adverse childhood experiences (ACEs), and physical activity in general and team sports in particular have been shown to improve mental health, wrote Molly C. Easterlin, MD, of the University of California, Los Angeles, and colleagues.

In a study published in JAMA Pediatrics, the researchers used data from the National Longitudinal Study of Adolescent to Adult Health to compare the development of depression, anxiety, or depressive symptoms among those with childhood ACEs who did and did not participate in team sports in adolescence.

Overall, team sports participation was significantly associated with reduced odds of depression (adjusted odds ratio, 0.76), anxiety (aOR, 0.70), and depressive symptoms (aOR, 0.85) in young adulthood for individuals with ACEs, compared with those with ACEs who did not play team sports.

Of 9,668 adolescents in the study, 4,888 individuals reported one or more ACEs and 2,084 reported two or more ACEs. The researchers compared data from the 1994-1995 school year when participants were in grades 7-12 and in 2008 to assess their mental health as young adults (aged 24-32 years).

No significant differences in associations appeared between sports participation and mental health between males and females.

The results were limited by several factors including the study design that did not allow for causality and the potential social desirability bias that might lead to underreporting ACEs, Dr. Easterlin and associates noted.

Nonetheless, “given that participation in team sports was associated with improved adult mental health among those with ACEs, pediatricians might consider recommending team sports participation for patients with ACEs and parents might consider enrolling their children with ACEs in team sports,” they wrote.

Dr. Easterlin is supported by the Cedars-Sinai Medical Center via the UCLA National Clinician Scholars Program. The authors reported no conflicts of interest.

SOURCE: Easterlin MC et al. JAMA Pediatr. 2019 May 28. doi: 10.1001/jamapediatrics.2019.1212.

Individuals who experienced adverse childhood experiences but also played team sports as teens were less likely to have mental health problems in adulthood than those with childhood challenges who did not play sports, based on data from nearly 5,000 individuals.

Mike Watson Images/Thinkstock

Physical and mental health problems are more prominent throughout life among those exposed to adverse childhood experiences (ACEs), and physical activity in general and team sports in particular have been shown to improve mental health, wrote Molly C. Easterlin, MD, of the University of California, Los Angeles, and colleagues.

In a study published in JAMA Pediatrics, the researchers used data from the National Longitudinal Study of Adolescent to Adult Health to compare the development of depression, anxiety, or depressive symptoms among those with childhood ACEs who did and did not participate in team sports in adolescence.

Overall, team sports participation was significantly associated with reduced odds of depression (adjusted odds ratio, 0.76), anxiety (aOR, 0.70), and depressive symptoms (aOR, 0.85) in young adulthood for individuals with ACEs, compared with those with ACEs who did not play team sports.

Of 9,668 adolescents in the study, 4,888 individuals reported one or more ACEs and 2,084 reported two or more ACEs. The researchers compared data from the 1994-1995 school year when participants were in grades 7-12 and in 2008 to assess their mental health as young adults (aged 24-32 years).

No significant differences in associations appeared between sports participation and mental health between males and females.

The results were limited by several factors including the study design that did not allow for causality and the potential social desirability bias that might lead to underreporting ACEs, Dr. Easterlin and associates noted.

Nonetheless, “given that participation in team sports was associated with improved adult mental health among those with ACEs, pediatricians might consider recommending team sports participation for patients with ACEs and parents might consider enrolling their children with ACEs in team sports,” they wrote.

Dr. Easterlin is supported by the Cedars-Sinai Medical Center via the UCLA National Clinician Scholars Program. The authors reported no conflicts of interest.

SOURCE: Easterlin MC et al. JAMA Pediatr. 2019 May 28. doi: 10.1001/jamapediatrics.2019.1212.

Presenters

Amit K. Pahwa, MD, FAAP; Nicola Orlov, MD, MPH, FAAP
 

Workshop title

Things we do for no reason (pediatrics)

Session summary

As he began by stating the Institute of Medicine definition of high-value care (HVC), Amit K. Pahwa, MD, of Johns Hopkins Medicine, Baltimore, described HVC as the best care for the patient, with the optimal result for the circumstances, at the right price. But few pediatric residency programs provide education regarding HVC, with only 11% providing a formal HVC curriculum, as found by a survey of pediatric program directors and chief residents in a study published in 2017.

Dr. Pahwa then provided examples of cases in which HVC could be optimized, including reducing rebound bilirubin levels in neonatal hyperbilirubinemia, giving nasogastric feeds instead of IV hydration in bronchiolitis, reducing unnecessary vital sign checks, and providing apple juice supplemented with liquids of choice instead of more expensive oral electrolyte solutions.

Nicola Orlov, MD, of the University of Chicago presented another illustrative case which highlighted the need to reduce vital sign frequency when appropriate. This was linked to her work at Comer Children’s Hospital on reducing nighttime sleep disruptions in hospitalized children, as part of the SIESTA (Sleep for Inpatients: Empowering Staff to Act) study. This led to a significant reduction in nurse/physician interruptions during the study period.
 

Key takeaways for HM

• High-value care (HVC) is a key focus of systems improvement in the field of pediatric hospital medicine.
• Educational efforts for all levels of learners is inadequate currently, and needs to be augmented.
• Quality improvement projects to promote HVC can lead not only to reduced costs, but improved quality and patient experience.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.

Presenters

Amit K. Pahwa, MD, FAAP; Nicola Orlov, MD, MPH, FAAP
 

Workshop title

Things we do for no reason (pediatrics)

Session summary

As he began by stating the Institute of Medicine definition of high-value care (HVC), Amit K. Pahwa, MD, of Johns Hopkins Medicine, Baltimore, described HVC as the best care for the patient, with the optimal result for the circumstances, at the right price. But few pediatric residency programs provide education regarding HVC, with only 11% providing a formal HVC curriculum, as found by a survey of pediatric program directors and chief residents in a study published in 2017.

Dr. Pahwa then provided examples of cases in which HVC could be optimized, including reducing rebound bilirubin levels in neonatal hyperbilirubinemia, giving nasogastric feeds instead of IV hydration in bronchiolitis, reducing unnecessary vital sign checks, and providing apple juice supplemented with liquids of choice instead of more expensive oral electrolyte solutions.

Nicola Orlov, MD, of the University of Chicago presented another illustrative case which highlighted the need to reduce vital sign frequency when appropriate. This was linked to her work at Comer Children’s Hospital on reducing nighttime sleep disruptions in hospitalized children, as part of the SIESTA (Sleep for Inpatients: Empowering Staff to Act) study. This led to a significant reduction in nurse/physician interruptions during the study period.
 

Key takeaways for HM

• High-value care (HVC) is a key focus of systems improvement in the field of pediatric hospital medicine.
• Educational efforts for all levels of learners is inadequate currently, and needs to be augmented.
• Quality improvement projects to promote HVC can lead not only to reduced costs, but improved quality and patient experience.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.

Presenters

Amit K. Pahwa, MD, FAAP; Nicola Orlov, MD, MPH, FAAP
 

Workshop title

Things we do for no reason (pediatrics)

Session summary

As he began by stating the Institute of Medicine definition of high-value care (HVC), Amit K. Pahwa, MD, of Johns Hopkins Medicine, Baltimore, described HVC as the best care for the patient, with the optimal result for the circumstances, at the right price. But few pediatric residency programs provide education regarding HVC, with only 11% providing a formal HVC curriculum, as found by a survey of pediatric program directors and chief residents in a study published in 2017.

Dr. Pahwa then provided examples of cases in which HVC could be optimized, including reducing rebound bilirubin levels in neonatal hyperbilirubinemia, giving nasogastric feeds instead of IV hydration in bronchiolitis, reducing unnecessary vital sign checks, and providing apple juice supplemented with liquids of choice instead of more expensive oral electrolyte solutions.

Nicola Orlov, MD, of the University of Chicago presented another illustrative case which highlighted the need to reduce vital sign frequency when appropriate. This was linked to her work at Comer Children’s Hospital on reducing nighttime sleep disruptions in hospitalized children, as part of the SIESTA (Sleep for Inpatients: Empowering Staff to Act) study. This led to a significant reduction in nurse/physician interruptions during the study period.
 

Key takeaways for HM

• High-value care (HVC) is a key focus of systems improvement in the field of pediatric hospital medicine.
• Educational efforts for all levels of learners is inadequate currently, and needs to be augmented.
• Quality improvement projects to promote HVC can lead not only to reduced costs, but improved quality and patient experience.

Dr. Chang is a pediatric hospitalist at Baystate Children’s Hospital in Springfield, Mass., and is the pediatric editor of The Hospitalist.

BIRMINGHAM, ENGLAND – Almost two-thirds of patients with axial spondyloarthritis (axSpA) have more than one medical condition, and these may cluster together, the results of a single-center, cross-sectional study have shown.

Of 419 patients, 61% had multiple conditions, with a median of at least one other condition in addition to axSpA, but some patients had as many as five. The most common other conditions in patients with axSpA were hypertension (19% of patients), depression (16%), and dyspepsia (11%).

In all, 15 clusters of conditions were found, each dominated by one or two conditions in addition to axSpA. The three largest clusters were hypertension and cardiovascular disease (n = 88), anxiety and depression (n = 50), and dyspepsia (n = 31). In the cohort, 69% of the patients were male; the mean age was 45 years.

“Multimorbidity and comorbidity both essentially mean the same thing but from different perspectives,” Sizheng Steven Zhao, MD, said at the annual conference of the British Society for Rheumatology.

“Many of us will be familiar with comorbidity and this is a concept that has one index disease at the center and we consider all other conditions to be coexisting. This is a model you typically see in hospital settings, so you go to see your rheumatologist for your axSpA and your cardiologist for your cardiovascular disease,” he explained.

“From a patient’s perspective, that’s probably a little less helpful to go from specialist to specialist, each only interested in one condition so, quite rightly, there’s been a push towards providing more holistic care with the patient at the center, and this is really encapsulated by the concept of multimorbidity, which is just defined as the coexistence of any two conditions.” The multimorbidity model is particularly suited to a primary care setting rather than a hospital setting, he added.

“Whatever you want to call it, it’s becoming more of a problem,” Dr. Zhao said. There is increasing multimorbidity as people age, and it’s a common problem in those with rheumatic diseases because of shared risk factors, the consequences of systemic inflammation, and how patients are treated.

Prior studies of multimorbidity in axSpA have either been of individual comorbid diseases or counts. Dr. Zhao, a clinical research fellow at Aintree University Hospital in Liverpool, England, and his associates looked at how coexisting conditions might cluster together to provide insight into how these might be better managed collectively in patients with axSpA.


The investigators used an adapted form of the Radner index for determining multimorbidity in patients consecutively seen at the Aintree University Hospital’s rheumatology clinic between 2010 and 2017. The Radner index was adapted to consider 40 chronic conditions, including fibromyalgia and osteoporosis but excluding rheumatic diseases and their extra-articular manifestations.

Dr. Zhao and his colleagues used regression models adjusted for age, gender, symptom duration, smoking status, body mass index, social deprivation, and NSAID use to see what, if any, effect having one of these clusters of multimorbid conditions might have on quality of life, general health, disease activity, and functional impairment measures. Patients with certain clusters of conditions had worse scores, particularly those with coexisting depression and/or anxiety and those with fibromyalgia, irritable bowel syndrome, or both in addition to axSpA.

“These are important conditions to be aware of in the management of axSpA patients,” Dr. Zhao said.

These data are consistent with what has already been published, with between 50% and 60% of patients having other conditions, particularly depression, said consultant rheumatologist Helena Marzo-Ortega, MD, of Leeds Teaching Hospitals NHS Trust, who chaired the session. “These are really important numbers for us to remember in the clinic,” she said.

None of the investigators reported having relevant disclosures.

SOURCE: Zhao S et al., Rheumatology 2019;58(suppl 3), Abstract 035.

BIRMINGHAM, ENGLAND – Almost two-thirds of patients with axial spondyloarthritis (axSpA) have more than one medical condition, and these may cluster together, the results of a single-center, cross-sectional study have shown.

Of 419 patients, 61% had multiple conditions, with a median of at least one other condition in addition to axSpA, but some patients had as many as five. The most common other conditions in patients with axSpA were hypertension (19% of patients), depression (16%), and dyspepsia (11%).

In all, 15 clusters of conditions were found, each dominated by one or two conditions in addition to axSpA. The three largest clusters were hypertension and cardiovascular disease (n = 88), anxiety and depression (n = 50), and dyspepsia (n = 31). In the cohort, 69% of the patients were male; the mean age was 45 years.

“Multimorbidity and comorbidity both essentially mean the same thing but from different perspectives,” Sizheng Steven Zhao, MD, said at the annual conference of the British Society for Rheumatology.

“Many of us will be familiar with comorbidity and this is a concept that has one index disease at the center and we consider all other conditions to be coexisting. This is a model you typically see in hospital settings, so you go to see your rheumatologist for your axSpA and your cardiologist for your cardiovascular disease,” he explained.

“From a patient’s perspective, that’s probably a little less helpful to go from specialist to specialist, each only interested in one condition so, quite rightly, there’s been a push towards providing more holistic care with the patient at the center, and this is really encapsulated by the concept of multimorbidity, which is just defined as the coexistence of any two conditions.” The multimorbidity model is particularly suited to a primary care setting rather than a hospital setting, he added.

“Whatever you want to call it, it’s becoming more of a problem,” Dr. Zhao said. There is increasing multimorbidity as people age, and it’s a common problem in those with rheumatic diseases because of shared risk factors, the consequences of systemic inflammation, and how patients are treated.

Prior studies of multimorbidity in axSpA have either been of individual comorbid diseases or counts. Dr. Zhao, a clinical research fellow at Aintree University Hospital in Liverpool, England, and his associates looked at how coexisting conditions might cluster together to provide insight into how these might be better managed collectively in patients with axSpA.


The investigators used an adapted form of the Radner index for determining multimorbidity in patients consecutively seen at the Aintree University Hospital’s rheumatology clinic between 2010 and 2017. The Radner index was adapted to consider 40 chronic conditions, including fibromyalgia and osteoporosis but excluding rheumatic diseases and their extra-articular manifestations.

Dr. Zhao and his colleagues used regression models adjusted for age, gender, symptom duration, smoking status, body mass index, social deprivation, and NSAID use to see what, if any, effect having one of these clusters of multimorbid conditions might have on quality of life, general health, disease activity, and functional impairment measures. Patients with certain clusters of conditions had worse scores, particularly those with coexisting depression and/or anxiety and those with fibromyalgia, irritable bowel syndrome, or both in addition to axSpA.

“These are important conditions to be aware of in the management of axSpA patients,” Dr. Zhao said.

These data are consistent with what has already been published, with between 50% and 60% of patients having other conditions, particularly depression, said consultant rheumatologist Helena Marzo-Ortega, MD, of Leeds Teaching Hospitals NHS Trust, who chaired the session. “These are really important numbers for us to remember in the clinic,” she said.

None of the investigators reported having relevant disclosures.

SOURCE: Zhao S et al., Rheumatology 2019;58(suppl 3), Abstract 035.

BIRMINGHAM, ENGLAND – Almost two-thirds of patients with axial spondyloarthritis (axSpA) have more than one medical condition, and these may cluster together, the results of a single-center, cross-sectional study have shown.

Of 419 patients, 61% had multiple conditions, with a median of at least one other condition in addition to axSpA, but some patients had as many as five. The most common other conditions in patients with axSpA were hypertension (19% of patients), depression (16%), and dyspepsia (11%).

In all, 15 clusters of conditions were found, each dominated by one or two conditions in addition to axSpA. The three largest clusters were hypertension and cardiovascular disease (n = 88), anxiety and depression (n = 50), and dyspepsia (n = 31). In the cohort, 69% of the patients were male; the mean age was 45 years.

“Multimorbidity and comorbidity both essentially mean the same thing but from different perspectives,” Sizheng Steven Zhao, MD, said at the annual conference of the British Society for Rheumatology.

“Many of us will be familiar with comorbidity and this is a concept that has one index disease at the center and we consider all other conditions to be coexisting. This is a model you typically see in hospital settings, so you go to see your rheumatologist for your axSpA and your cardiologist for your cardiovascular disease,” he explained.

“From a patient’s perspective, that’s probably a little less helpful to go from specialist to specialist, each only interested in one condition so, quite rightly, there’s been a push towards providing more holistic care with the patient at the center, and this is really encapsulated by the concept of multimorbidity, which is just defined as the coexistence of any two conditions.” The multimorbidity model is particularly suited to a primary care setting rather than a hospital setting, he added.

“Whatever you want to call it, it’s becoming more of a problem,” Dr. Zhao said. There is increasing multimorbidity as people age, and it’s a common problem in those with rheumatic diseases because of shared risk factors, the consequences of systemic inflammation, and how patients are treated.

Prior studies of multimorbidity in axSpA have either been of individual comorbid diseases or counts. Dr. Zhao, a clinical research fellow at Aintree University Hospital in Liverpool, England, and his associates looked at how coexisting conditions might cluster together to provide insight into how these might be better managed collectively in patients with axSpA.


The investigators used an adapted form of the Radner index for determining multimorbidity in patients consecutively seen at the Aintree University Hospital’s rheumatology clinic between 2010 and 2017. The Radner index was adapted to consider 40 chronic conditions, including fibromyalgia and osteoporosis but excluding rheumatic diseases and their extra-articular manifestations.

Dr. Zhao and his colleagues used regression models adjusted for age, gender, symptom duration, smoking status, body mass index, social deprivation, and NSAID use to see what, if any, effect having one of these clusters of multimorbid conditions might have on quality of life, general health, disease activity, and functional impairment measures. Patients with certain clusters of conditions had worse scores, particularly those with coexisting depression and/or anxiety and those with fibromyalgia, irritable bowel syndrome, or both in addition to axSpA.

“These are important conditions to be aware of in the management of axSpA patients,” Dr. Zhao said.

These data are consistent with what has already been published, with between 50% and 60% of patients having other conditions, particularly depression, said consultant rheumatologist Helena Marzo-Ortega, MD, of Leeds Teaching Hospitals NHS Trust, who chaired the session. “These are really important numbers for us to remember in the clinic,” she said.

None of the investigators reported having relevant disclosures.

SOURCE: Zhao S et al., Rheumatology 2019;58(suppl 3), Abstract 035.

SAN FRANCISCO – Borderline personality disorder is often treated with long-running psychotherapy, but this could be a disservice to patients. Instead, stepped-care models may offer more benefit in a shorter period of time, conserving resources and potentially expanding the reach of therapeutic interventions.

“There is this legacy of psychoanalysis, this idea that if you’ve had a condition for 20 years, it’s going to take 20 years of therapy to get rid of it – which is not true,” Joel Paris, MD, said in an interview. Dr. Paris moderated a session on stepped-care interventions for borderline personality disorder at the annual meeting of the American Psychiatric Association.

He also pointed out that psychoanalysis can prove self-sustaining: “There’s something to talk about, so it can go on and if there’s money to pay for the service, why stop?”

But psychoanalysis can have diminishing returns, and that in turn can strain resources. “Some people won’t get better or won’t go beyond a certain point. You help them to a certain extent, and then you have to be able to say, ‘That’s enough; stop there. If you get in to bad trouble, you can always come back,’ ” said Dr. Paris, professor of psychiatry at McGill University, Montreal.

That realization has led Dr. McGill to introduce a stepped-care model, which has provided a 12-week program for 15 years. Dr. Paris presented a retrospective look at the program, including 479 patients who received individual and group therapy. The dropout rate was high at 30%, but only 12% of patients returned asking for more therapy. A total of 145 patients deemed to be more chronic or who did not respond to the short-term program had the option of completing additional individual or group therapy over a period of 6-24 months.

“Eighty-eight percent of patients don’t come back, and we’re happy with that. There are also dropouts; maybe a quarter will not complete the program,” Dr. Paris said. “But that means 75% do, and most of them get better. There’s also good evidence that short therapy can help many people with substance abuse.”

Lois W. Choi-Kain, MD, assistant professor psychiatry at Harvard Medical School, Boston, presented evidence from several studies showing that shorter- and long-term courses of dialectical behavior therapy led to similar improvements, but that brief courses were associated with more rapid improvement. The short course consisted of weekly 1-hour individual sessions, while the longer course involved weekly 2-hour group sessions. The individual approach was associated with an 89% faster improvement in symptoms in the first 3 months (P less than .0001).

These kinds of findings underscore the need for shorter courses of therapy, at least for most patients, in order to conserve resources and broaden the availability of therapy, particularly in less affluent settings. “We saw in today’s symposium that most improvement takes place at the beginning of therapy, and you should quit while you’re ahead,” Dr. Paris said. “You should not try to do impossible things and make everybody into paradigms of mental health.”

Dr. Paris reported no relevant financial disclosures.

SAN FRANCISCO – Borderline personality disorder is often treated with long-running psychotherapy, but this could be a disservice to patients. Instead, stepped-care models may offer more benefit in a shorter period of time, conserving resources and potentially expanding the reach of therapeutic interventions.

“There is this legacy of psychoanalysis, this idea that if you’ve had a condition for 20 years, it’s going to take 20 years of therapy to get rid of it – which is not true,” Joel Paris, MD, said in an interview. Dr. Paris moderated a session on stepped-care interventions for borderline personality disorder at the annual meeting of the American Psychiatric Association.

He also pointed out that psychoanalysis can prove self-sustaining: “There’s something to talk about, so it can go on and if there’s money to pay for the service, why stop?”

But psychoanalysis can have diminishing returns, and that in turn can strain resources. “Some people won’t get better or won’t go beyond a certain point. You help them to a certain extent, and then you have to be able to say, ‘That’s enough; stop there. If you get in to bad trouble, you can always come back,’ ” said Dr. Paris, professor of psychiatry at McGill University, Montreal.

That realization has led Dr. McGill to introduce a stepped-care model, which has provided a 12-week program for 15 years. Dr. Paris presented a retrospective look at the program, including 479 patients who received individual and group therapy. The dropout rate was high at 30%, but only 12% of patients returned asking for more therapy. A total of 145 patients deemed to be more chronic or who did not respond to the short-term program had the option of completing additional individual or group therapy over a period of 6-24 months.

“Eighty-eight percent of patients don’t come back, and we’re happy with that. There are also dropouts; maybe a quarter will not complete the program,” Dr. Paris said. “But that means 75% do, and most of them get better. There’s also good evidence that short therapy can help many people with substance abuse.”

Lois W. Choi-Kain, MD, assistant professor psychiatry at Harvard Medical School, Boston, presented evidence from several studies showing that shorter- and long-term courses of dialectical behavior therapy led to similar improvements, but that brief courses were associated with more rapid improvement. The short course consisted of weekly 1-hour individual sessions, while the longer course involved weekly 2-hour group sessions. The individual approach was associated with an 89% faster improvement in symptoms in the first 3 months (P less than .0001).

These kinds of findings underscore the need for shorter courses of therapy, at least for most patients, in order to conserve resources and broaden the availability of therapy, particularly in less affluent settings. “We saw in today’s symposium that most improvement takes place at the beginning of therapy, and you should quit while you’re ahead,” Dr. Paris said. “You should not try to do impossible things and make everybody into paradigms of mental health.”

Dr. Paris reported no relevant financial disclosures.

SAN FRANCISCO – Borderline personality disorder is often treated with long-running psychotherapy, but this could be a disservice to patients. Instead, stepped-care models may offer more benefit in a shorter period of time, conserving resources and potentially expanding the reach of therapeutic interventions.

“There is this legacy of psychoanalysis, this idea that if you’ve had a condition for 20 years, it’s going to take 20 years of therapy to get rid of it – which is not true,” Joel Paris, MD, said in an interview. Dr. Paris moderated a session on stepped-care interventions for borderline personality disorder at the annual meeting of the American Psychiatric Association.

He also pointed out that psychoanalysis can prove self-sustaining: “There’s something to talk about, so it can go on and if there’s money to pay for the service, why stop?”

But psychoanalysis can have diminishing returns, and that in turn can strain resources. “Some people won’t get better or won’t go beyond a certain point. You help them to a certain extent, and then you have to be able to say, ‘That’s enough; stop there. If you get in to bad trouble, you can always come back,’ ” said Dr. Paris, professor of psychiatry at McGill University, Montreal.

That realization has led Dr. McGill to introduce a stepped-care model, which has provided a 12-week program for 15 years. Dr. Paris presented a retrospective look at the program, including 479 patients who received individual and group therapy. The dropout rate was high at 30%, but only 12% of patients returned asking for more therapy. A total of 145 patients deemed to be more chronic or who did not respond to the short-term program had the option of completing additional individual or group therapy over a period of 6-24 months.

“Eighty-eight percent of patients don’t come back, and we’re happy with that. There are also dropouts; maybe a quarter will not complete the program,” Dr. Paris said. “But that means 75% do, and most of them get better. There’s also good evidence that short therapy can help many people with substance abuse.”

Lois W. Choi-Kain, MD, assistant professor psychiatry at Harvard Medical School, Boston, presented evidence from several studies showing that shorter- and long-term courses of dialectical behavior therapy led to similar improvements, but that brief courses were associated with more rapid improvement. The short course consisted of weekly 1-hour individual sessions, while the longer course involved weekly 2-hour group sessions. The individual approach was associated with an 89% faster improvement in symptoms in the first 3 months (P less than .0001).

These kinds of findings underscore the need for shorter courses of therapy, at least for most patients, in order to conserve resources and broaden the availability of therapy, particularly in less affluent settings. “We saw in today’s symposium that most improvement takes place at the beginning of therapy, and you should quit while you’re ahead,” Dr. Paris said. “You should not try to do impossible things and make everybody into paradigms of mental health.”

Dr. Paris reported no relevant financial disclosures.

SAN FRANCISCO – Smartphones are nearly ubiquitous, and the apps available on them run the gamut from entertainment to social media, organization tools, and references. It should be no surprise that mental health applications are also gaining traction, as people experiencing depression, anxiety, and other conditions turn to these programs for assistance.

Psychiatrists should be aware of any mental health apps that their patients are using, and they should do a little research to determine their safety and efficacy, according to Hephsibah M. Loeb, MD, a psychiatry resident at Jefferson Medical College, Philadelphia.

“It’s our responsibility to understand the medications we’re prescribing, so I don’t think this is any different,” said Dr. Loeb, who presented a poster outlining advice for clinicians at the annual meeting of the American Psychiatric Association.

One such app, called reSET, gained approval from Food and Drug Administration for the treatment of alcohol, cocaine, marijuana, and stimulant use disorders. Another app, called PRIME-D, designed for self-management of depression, showed some benefit in an open-label study. But there are many more apps out there, and how is a clinician to know of the potential benefits and hazards?

In her poster, Dr. Loeb outlined the APA’s App Evaluation tool, which is designed to help clinicians systematically investigate an app. The APA has no standing list of reviewed apps because they are changing all the time, and new apps are introduced and removed all the time.

“The evaluation model is a set of questions that the APA developed [representing] certain issues that if a patient reports using an app, a clinician should look into in order to determine if it’s an appropriate and safe tool. For example: Who developed the app? What is its privacy policy? Is the information correct?” Dr. Loeb asked.

Privacy is of particular concern, since the patient has no way of knowing how his or her data are being handled. “If you’re putting really personal stuff in there and you don’t know where it’s going, that’s a huge risk. We have HIPAA protection in the office, but needless to say, if someone downloads something from the app store, their information is not going to be protected by HIPAA,” Dr. Loeb said.

Despite these concerns, Dr. Loeb is not a naysayer. “I think that self-help is really interesting. Presumably, there are patients we’re not even seeing in the office,” she said. In some cases, people are not patients but have a complaint and need help. “If there weren’t an app or online therapy, they might not otherwise get help.”

But whether the help they’re getting is reliable is another question. “There’s the chance that the information is perfectly accurate; there’s the chance that there’s misinformation. There’s also the chance of mis–self-diagnosis,” Dr. Loeb said.

She specifically advises that clinicians recommend apps to their patients that permit data sharing with the clinician, since better clinical outcomes with apps are associated with receiving support from a trained mental health coach.

Finally, there’s one sure way to determine the quality of an app: Dr. Loeb said that a coauthor on the poster, Ann Chandy, MD, a clinical professor of psychiatry at Jefferson Medical College, uses an app herself when a patient brings it to her attention.

Dr. Loeb reported no relevant financial disclosures.

SAN FRANCISCO – Smartphones are nearly ubiquitous, and the apps available on them run the gamut from entertainment to social media, organization tools, and references. It should be no surprise that mental health applications are also gaining traction, as people experiencing depression, anxiety, and other conditions turn to these programs for assistance.

Psychiatrists should be aware of any mental health apps that their patients are using, and they should do a little research to determine their safety and efficacy, according to Hephsibah M. Loeb, MD, a psychiatry resident at Jefferson Medical College, Philadelphia.

“It’s our responsibility to understand the medications we’re prescribing, so I don’t think this is any different,” said Dr. Loeb, who presented a poster outlining advice for clinicians at the annual meeting of the American Psychiatric Association.

One such app, called reSET, gained approval from Food and Drug Administration for the treatment of alcohol, cocaine, marijuana, and stimulant use disorders. Another app, called PRIME-D, designed for self-management of depression, showed some benefit in an open-label study. But there are many more apps out there, and how is a clinician to know of the potential benefits and hazards?

In her poster, Dr. Loeb outlined the APA’s App Evaluation tool, which is designed to help clinicians systematically investigate an app. The APA has no standing list of reviewed apps because they are changing all the time, and new apps are introduced and removed all the time.

“The evaluation model is a set of questions that the APA developed [representing] certain issues that if a patient reports using an app, a clinician should look into in order to determine if it’s an appropriate and safe tool. For example: Who developed the app? What is its privacy policy? Is the information correct?” Dr. Loeb asked.

Privacy is of particular concern, since the patient has no way of knowing how his or her data are being handled. “If you’re putting really personal stuff in there and you don’t know where it’s going, that’s a huge risk. We have HIPAA protection in the office, but needless to say, if someone downloads something from the app store, their information is not going to be protected by HIPAA,” Dr. Loeb said.

Despite these concerns, Dr. Loeb is not a naysayer. “I think that self-help is really interesting. Presumably, there are patients we’re not even seeing in the office,” she said. In some cases, people are not patients but have a complaint and need help. “If there weren’t an app or online therapy, they might not otherwise get help.”

But whether the help they’re getting is reliable is another question. “There’s the chance that the information is perfectly accurate; there’s the chance that there’s misinformation. There’s also the chance of mis–self-diagnosis,” Dr. Loeb said.

She specifically advises that clinicians recommend apps to their patients that permit data sharing with the clinician, since better clinical outcomes with apps are associated with receiving support from a trained mental health coach.

Finally, there’s one sure way to determine the quality of an app: Dr. Loeb said that a coauthor on the poster, Ann Chandy, MD, a clinical professor of psychiatry at Jefferson Medical College, uses an app herself when a patient brings it to her attention.

Dr. Loeb reported no relevant financial disclosures.

SAN FRANCISCO – Smartphones are nearly ubiquitous, and the apps available on them run the gamut from entertainment to social media, organization tools, and references. It should be no surprise that mental health applications are also gaining traction, as people experiencing depression, anxiety, and other conditions turn to these programs for assistance.

Psychiatrists should be aware of any mental health apps that their patients are using, and they should do a little research to determine their safety and efficacy, according to Hephsibah M. Loeb, MD, a psychiatry resident at Jefferson Medical College, Philadelphia.

“It’s our responsibility to understand the medications we’re prescribing, so I don’t think this is any different,” said Dr. Loeb, who presented a poster outlining advice for clinicians at the annual meeting of the American Psychiatric Association.

One such app, called reSET, gained approval from Food and Drug Administration for the treatment of alcohol, cocaine, marijuana, and stimulant use disorders. Another app, called PRIME-D, designed for self-management of depression, showed some benefit in an open-label study. But there are many more apps out there, and how is a clinician to know of the potential benefits and hazards?

In her poster, Dr. Loeb outlined the APA’s App Evaluation tool, which is designed to help clinicians systematically investigate an app. The APA has no standing list of reviewed apps because they are changing all the time, and new apps are introduced and removed all the time.

“The evaluation model is a set of questions that the APA developed [representing] certain issues that if a patient reports using an app, a clinician should look into in order to determine if it’s an appropriate and safe tool. For example: Who developed the app? What is its privacy policy? Is the information correct?” Dr. Loeb asked.

Privacy is of particular concern, since the patient has no way of knowing how his or her data are being handled. “If you’re putting really personal stuff in there and you don’t know where it’s going, that’s a huge risk. We have HIPAA protection in the office, but needless to say, if someone downloads something from the app store, their information is not going to be protected by HIPAA,” Dr. Loeb said.

Despite these concerns, Dr. Loeb is not a naysayer. “I think that self-help is really interesting. Presumably, there are patients we’re not even seeing in the office,” she said. In some cases, people are not patients but have a complaint and need help. “If there weren’t an app or online therapy, they might not otherwise get help.”

But whether the help they’re getting is reliable is another question. “There’s the chance that the information is perfectly accurate; there’s the chance that there’s misinformation. There’s also the chance of mis–self-diagnosis,” Dr. Loeb said.

She specifically advises that clinicians recommend apps to their patients that permit data sharing with the clinician, since better clinical outcomes with apps are associated with receiving support from a trained mental health coach.

Finally, there’s one sure way to determine the quality of an app: Dr. Loeb said that a coauthor on the poster, Ann Chandy, MD, a clinical professor of psychiatry at Jefferson Medical College, uses an app herself when a patient brings it to her attention.

Dr. Loeb reported no relevant financial disclosures.

A genetic analysis of patients with chronic lymphocytic leukemia treated with frontline, rituximab-based regimens found that deletion 11q22 and unmutated IgVH status may predict worse prognosis.

Michaela Spunarova, MD, of Masaryk University, Brno, Czech Republic, and colleagues conducted a genetic analysis of 177 patients with chronic lymphocytic leukemia (CLL). The results of the analysis were published in Leukemia Research.

The study focused on patients with CLL with an intact TP53 gene, looking at recurrently muted genes in CLL, genomic aberrations by fluorescence in situ hybridization, and IgVH status, according to the researchers.

The team analyzed the effects of these mutations on progression-free survival (PFS) following frontline treatment with bendamustine and rituximab (BR) or fludarabine, cyclophosphamide, and rituximab (FCR) therapeutic regimens.

Dr. Spunarova and colleagues used next-generation sequencing to analyze DNA from the patient samples. Data on 11q22, 13q14, trisomy 12, and IgVH mutation status were also considered in the analyses of PFS.

After analysis, the researchers validated that unmutated IgVH status is an indicator of poor prognosis in CLL patients with wild-type TP53 treated with frontline FCR.

When looking at both BR and FCR regimens, a single 11q22 deletion, lacking an ATM mutation on the other allele, resulted in the shortest PFS, at a median of just 16 months.

“Based on our data, special attention should be given to CLL patients harboring a sole 11q22 deletion, with no ATM mutation on the other allele, who manifest particularly short PFS,” they noted.

The researchers acknowledged a key limitation of the study was the small sample size. As a result, the results should be interpreted in a careful manner.

The study was funded by the Ministry of Health of the Czech Republic. The authors reported having no conflicts of interest.

SOURCE: Spunarova M et al. Leuk Res. 2019 Jun;81:75-81.

A genetic analysis of patients with chronic lymphocytic leukemia treated with frontline, rituximab-based regimens found that deletion 11q22 and unmutated IgVH status may predict worse prognosis.

Michaela Spunarova, MD, of Masaryk University, Brno, Czech Republic, and colleagues conducted a genetic analysis of 177 patients with chronic lymphocytic leukemia (CLL). The results of the analysis were published in Leukemia Research.

The study focused on patients with CLL with an intact TP53 gene, looking at recurrently muted genes in CLL, genomic aberrations by fluorescence in situ hybridization, and IgVH status, according to the researchers.

The team analyzed the effects of these mutations on progression-free survival (PFS) following frontline treatment with bendamustine and rituximab (BR) or fludarabine, cyclophosphamide, and rituximab (FCR) therapeutic regimens.

Dr. Spunarova and colleagues used next-generation sequencing to analyze DNA from the patient samples. Data on 11q22, 13q14, trisomy 12, and IgVH mutation status were also considered in the analyses of PFS.

After analysis, the researchers validated that unmutated IgVH status is an indicator of poor prognosis in CLL patients with wild-type TP53 treated with frontline FCR.

When looking at both BR and FCR regimens, a single 11q22 deletion, lacking an ATM mutation on the other allele, resulted in the shortest PFS, at a median of just 16 months.

“Based on our data, special attention should be given to CLL patients harboring a sole 11q22 deletion, with no ATM mutation on the other allele, who manifest particularly short PFS,” they noted.

The researchers acknowledged a key limitation of the study was the small sample size. As a result, the results should be interpreted in a careful manner.

The study was funded by the Ministry of Health of the Czech Republic. The authors reported having no conflicts of interest.

SOURCE: Spunarova M et al. Leuk Res. 2019 Jun;81:75-81.

A genetic analysis of patients with chronic lymphocytic leukemia treated with frontline, rituximab-based regimens found that deletion 11q22 and unmutated IgVH status may predict worse prognosis.

Michaela Spunarova, MD, of Masaryk University, Brno, Czech Republic, and colleagues conducted a genetic analysis of 177 patients with chronic lymphocytic leukemia (CLL). The results of the analysis were published in Leukemia Research.

The study focused on patients with CLL with an intact TP53 gene, looking at recurrently muted genes in CLL, genomic aberrations by fluorescence in situ hybridization, and IgVH status, according to the researchers.

The team analyzed the effects of these mutations on progression-free survival (PFS) following frontline treatment with bendamustine and rituximab (BR) or fludarabine, cyclophosphamide, and rituximab (FCR) therapeutic regimens.

Dr. Spunarova and colleagues used next-generation sequencing to analyze DNA from the patient samples. Data on 11q22, 13q14, trisomy 12, and IgVH mutation status were also considered in the analyses of PFS.

After analysis, the researchers validated that unmutated IgVH status is an indicator of poor prognosis in CLL patients with wild-type TP53 treated with frontline FCR.

When looking at both BR and FCR regimens, a single 11q22 deletion, lacking an ATM mutation on the other allele, resulted in the shortest PFS, at a median of just 16 months.

“Based on our data, special attention should be given to CLL patients harboring a sole 11q22 deletion, with no ATM mutation on the other allele, who manifest particularly short PFS,” they noted.

The researchers acknowledged a key limitation of the study was the small sample size. As a result, the results should be interpreted in a careful manner.

The study was funded by the Ministry of Health of the Czech Republic. The authors reported having no conflicts of interest.

SOURCE: Spunarova M et al. Leuk Res. 2019 Jun;81:75-81.

SAN FRANCISCO – An expert in obsessive-compulsive disease had some surprising advice at the American Psychiatric Association annual meeting for treatment of adults with refractory illness. He endorsed amphetamines, caffeine, and once-weekly opioids in carefully selected patients.

M. Alexander Otto/MDedge News

“These are not things that will be taught to you in your residency,” said Lorrin M. Koran, MD, professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University, and past director of the university’s OCD clinic and research program. “These are pharmacological pearls that have come to my attention over many years. I hope at the end of this talk you’ll be more comfortable, especially [with] stimulants, because [they are] very simple and very quick.”

Opioids are a last resort but can prove effective for some patients. “I had a woman who wrote me just last week who said her son’s been on an opioid for 9 years once a week,” Dr. Koran said. “He does very well, and if he stops, he relapses within a few days. He has not become dependent or abusive. You have to screen who you give these to.

“You and I are dedicated to helping people not suffer, so we might want to take a little risk” for people who are struggling, he said.

Bolus caffeine, not a casual cup

Inspired by findings from the 1980s-90s, Dr. Koran and his colleagues randomized 12 treatment-resistant adults at Stanford’s OCD clinic to dextroamphetamine (Dexedrine) 30 mg/day and 12 others to caffeine (NoDoz pills) 300 mg/day, both in pink capsules so patients couldn’t tell them apart. “They were really sick” at baseline, Dr. Koran said, with a mean Yale Brown OCD Scale (YBOCS) score of 28 points (J Clin Psychiatry. 2009 Nov;70[11]:1530-5).

Subjects remained on their antidepressants during the study. Patients with histories of substance abuse, heart disease, schizophrenia, bipolar disorder, or panic attacks were among those excluded.

Caffeine was supposed to be the placebo. But a curious thing happened: About half of patients in both groups did remarkably well after 1 week, with a mean YBOCS drop of 41% among the six amphetamine responders and 45% among seven caffeine responders – with more improvement after 5 weeks.

“I was shocked. In clinical trials, anything 25% or more is considered a response. What patients said was, ‘Gee doc, I still get my obsessions, but I can shift my attention. I can get away from them, so I don’t have to do my compulsions, anymore,’ ” Dr. Koran said.

There were a few dose reductions for insomnia and anxiety. However, overall, YBOCS improvement did not correlate with depression and anxiety scores, so responses appeared to be independent. There were no differences between the groups in liking their treatment or how high people felt.

“I encourage you to try this” – amphetamine or caffeine bolus – “for people who have not responded to say two [treatment] trials. It’s simple. It’s safe. It’s quick. You know within 3 days, 5 days, and it lasts.” Meanwhile, “the data for methylphenidate are less convincing,” Dr. Koran said.

He’s wondered why caffeine helps. After all, no one has ever come into the OCD clinic and said they felt better after their morning coffee. The hypothesis is that 300 mg of caffeine all at once triggers a spike of methylxanthines in the brain, which, much like amphetamines, promotes dopamine and serotonin release. Casually sipping coffee does not have the same effect.

When all else fails

Dr. Koran and his colleagues also ran a small trial of once-weekly opiates.

Spurred again by case histories and small studies, they randomized 23 refractory adults to once-weekly morphine 30 mg (with 15-mg dose adjustment as needed at 2 weeks), lorazepam 1 mg (with 0.5-mg adjustment at 2 weeks), or placebo. Subjects had OCD for at least 3 years, and had failed at least two antidepressant trials (some had been on atypicals). Median baseline YBOCS was 29 points. Subjects remained on their baseline medications during the study (J Clin Psychiatry. 2005 Mar;66[3]:353-9).

Seven patients responded to morphine with a drop of at least 25% in their YBOCS; five had at least a 40% drop. Patients who were not taking a selective serotonin or norepinephrine reuptake inhibitor did not respond to morphine.

There were four lorazepam responders, but only one with a reduction of 40% or more. There were no placebo responders.

Opioids are the “the last thing to think of” in OCD, but when all else fails, “you could try morphine in a properly screened individual,” as long as there is no personal or family history of substance abuse.

Dr. Koran said he had no conflicts of interest.

aotto@mdedge.com

SAN FRANCISCO – An expert in obsessive-compulsive disease had some surprising advice at the American Psychiatric Association annual meeting for treatment of adults with refractory illness. He endorsed amphetamines, caffeine, and once-weekly opioids in carefully selected patients.

M. Alexander Otto/MDedge News

“These are not things that will be taught to you in your residency,” said Lorrin M. Koran, MD, professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University, and past director of the university’s OCD clinic and research program. “These are pharmacological pearls that have come to my attention over many years. I hope at the end of this talk you’ll be more comfortable, especially [with] stimulants, because [they are] very simple and very quick.”

Opioids are a last resort but can prove effective for some patients. “I had a woman who wrote me just last week who said her son’s been on an opioid for 9 years once a week,” Dr. Koran said. “He does very well, and if he stops, he relapses within a few days. He has not become dependent or abusive. You have to screen who you give these to.

“You and I are dedicated to helping people not suffer, so we might want to take a little risk” for people who are struggling, he said.

Bolus caffeine, not a casual cup

Inspired by findings from the 1980s-90s, Dr. Koran and his colleagues randomized 12 treatment-resistant adults at Stanford’s OCD clinic to dextroamphetamine (Dexedrine) 30 mg/day and 12 others to caffeine (NoDoz pills) 300 mg/day, both in pink capsules so patients couldn’t tell them apart. “They were really sick” at baseline, Dr. Koran said, with a mean Yale Brown OCD Scale (YBOCS) score of 28 points (J Clin Psychiatry. 2009 Nov;70[11]:1530-5).

Subjects remained on their antidepressants during the study. Patients with histories of substance abuse, heart disease, schizophrenia, bipolar disorder, or panic attacks were among those excluded.

Caffeine was supposed to be the placebo. But a curious thing happened: About half of patients in both groups did remarkably well after 1 week, with a mean YBOCS drop of 41% among the six amphetamine responders and 45% among seven caffeine responders – with more improvement after 5 weeks.

“I was shocked. In clinical trials, anything 25% or more is considered a response. What patients said was, ‘Gee doc, I still get my obsessions, but I can shift my attention. I can get away from them, so I don’t have to do my compulsions, anymore,’ ” Dr. Koran said.

There were a few dose reductions for insomnia and anxiety. However, overall, YBOCS improvement did not correlate with depression and anxiety scores, so responses appeared to be independent. There were no differences between the groups in liking their treatment or how high people felt.

“I encourage you to try this” – amphetamine or caffeine bolus – “for people who have not responded to say two [treatment] trials. It’s simple. It’s safe. It’s quick. You know within 3 days, 5 days, and it lasts.” Meanwhile, “the data for methylphenidate are less convincing,” Dr. Koran said.

He’s wondered why caffeine helps. After all, no one has ever come into the OCD clinic and said they felt better after their morning coffee. The hypothesis is that 300 mg of caffeine all at once triggers a spike of methylxanthines in the brain, which, much like amphetamines, promotes dopamine and serotonin release. Casually sipping coffee does not have the same effect.

When all else fails

Dr. Koran and his colleagues also ran a small trial of once-weekly opiates.

Spurred again by case histories and small studies, they randomized 23 refractory adults to once-weekly morphine 30 mg (with 15-mg dose adjustment as needed at 2 weeks), lorazepam 1 mg (with 0.5-mg adjustment at 2 weeks), or placebo. Subjects had OCD for at least 3 years, and had failed at least two antidepressant trials (some had been on atypicals). Median baseline YBOCS was 29 points. Subjects remained on their baseline medications during the study (J Clin Psychiatry. 2005 Mar;66[3]:353-9).

Seven patients responded to morphine with a drop of at least 25% in their YBOCS; five had at least a 40% drop. Patients who were not taking a selective serotonin or norepinephrine reuptake inhibitor did not respond to morphine.

There were four lorazepam responders, but only one with a reduction of 40% or more. There were no placebo responders.

Opioids are the “the last thing to think of” in OCD, but when all else fails, “you could try morphine in a properly screened individual,” as long as there is no personal or family history of substance abuse.

Dr. Koran said he had no conflicts of interest.

aotto@mdedge.com

SAN FRANCISCO – An expert in obsessive-compulsive disease had some surprising advice at the American Psychiatric Association annual meeting for treatment of adults with refractory illness. He endorsed amphetamines, caffeine, and once-weekly opioids in carefully selected patients.

M. Alexander Otto/MDedge News

“These are not things that will be taught to you in your residency,” said Lorrin M. Koran, MD, professor emeritus of psychiatry and behavioral sciences at Stanford (Calif.) University, and past director of the university’s OCD clinic and research program. “These are pharmacological pearls that have come to my attention over many years. I hope at the end of this talk you’ll be more comfortable, especially [with] stimulants, because [they are] very simple and very quick.”

Opioids are a last resort but can prove effective for some patients. “I had a woman who wrote me just last week who said her son’s been on an opioid for 9 years once a week,” Dr. Koran said. “He does very well, and if he stops, he relapses within a few days. He has not become dependent or abusive. You have to screen who you give these to.

“You and I are dedicated to helping people not suffer, so we might want to take a little risk” for people who are struggling, he said.

Bolus caffeine, not a casual cup

Inspired by findings from the 1980s-90s, Dr. Koran and his colleagues randomized 12 treatment-resistant adults at Stanford’s OCD clinic to dextroamphetamine (Dexedrine) 30 mg/day and 12 others to caffeine (NoDoz pills) 300 mg/day, both in pink capsules so patients couldn’t tell them apart. “They were really sick” at baseline, Dr. Koran said, with a mean Yale Brown OCD Scale (YBOCS) score of 28 points (J Clin Psychiatry. 2009 Nov;70[11]:1530-5).

Subjects remained on their antidepressants during the study. Patients with histories of substance abuse, heart disease, schizophrenia, bipolar disorder, or panic attacks were among those excluded.

Caffeine was supposed to be the placebo. But a curious thing happened: About half of patients in both groups did remarkably well after 1 week, with a mean YBOCS drop of 41% among the six amphetamine responders and 45% among seven caffeine responders – with more improvement after 5 weeks.

“I was shocked. In clinical trials, anything 25% or more is considered a response. What patients said was, ‘Gee doc, I still get my obsessions, but I can shift my attention. I can get away from them, so I don’t have to do my compulsions, anymore,’ ” Dr. Koran said.

There were a few dose reductions for insomnia and anxiety. However, overall, YBOCS improvement did not correlate with depression and anxiety scores, so responses appeared to be independent. There were no differences between the groups in liking their treatment or how high people felt.

“I encourage you to try this” – amphetamine or caffeine bolus – “for people who have not responded to say two [treatment] trials. It’s simple. It’s safe. It’s quick. You know within 3 days, 5 days, and it lasts.” Meanwhile, “the data for methylphenidate are less convincing,” Dr. Koran said.

He’s wondered why caffeine helps. After all, no one has ever come into the OCD clinic and said they felt better after their morning coffee. The hypothesis is that 300 mg of caffeine all at once triggers a spike of methylxanthines in the brain, which, much like amphetamines, promotes dopamine and serotonin release. Casually sipping coffee does not have the same effect.

When all else fails

Dr. Koran and his colleagues also ran a small trial of once-weekly opiates.

Spurred again by case histories and small studies, they randomized 23 refractory adults to once-weekly morphine 30 mg (with 15-mg dose adjustment as needed at 2 weeks), lorazepam 1 mg (with 0.5-mg adjustment at 2 weeks), or placebo. Subjects had OCD for at least 3 years, and had failed at least two antidepressant trials (some had been on atypicals). Median baseline YBOCS was 29 points. Subjects remained on their baseline medications during the study (J Clin Psychiatry. 2005 Mar;66[3]:353-9).

Seven patients responded to morphine with a drop of at least 25% in their YBOCS; five had at least a 40% drop. Patients who were not taking a selective serotonin or norepinephrine reuptake inhibitor did not respond to morphine.

There were four lorazepam responders, but only one with a reduction of 40% or more. There were no placebo responders.

Opioids are the “the last thing to think of” in OCD, but when all else fails, “you could try morphine in a properly screened individual,” as long as there is no personal or family history of substance abuse.

Dr. Koran said he had no conflicts of interest.

aotto@mdedge.com